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Background There is a paucity of data on management strategies and clinical outcomes after recurrent venous thromboembolism (VTE). Method In a multicenter registry enrolling 3027 patients with acute symptomatic VTE, the current study population was divided into the following 3 groups: 1) First recurrent VTE on anticoagulation therapy (N = 110); 2) First recurrent VTE off anticoagulation therapy (N = 116); and 3) No recurrent VTE (N = 2801). Results Patients with first recurrent VTE on anticoagulation therapy more often had active cancer (45%, 25%, and 22%, P < 0.001). Among 110 patients with first recurrent VTE on anticoagulation therapy, 84 patients (76%) received warfarin at recurrent VTE with the median prothrombin time-international normalized ratio (PT-INR) value at recurrent VTE of 1.6, although patients with active cancer had a significantly higher median PT-INR value at recurrent VTE compared with those without active cancer (2.0 versus 1.4, P < 0.001). Within 90 days after recurrent VTE, 23 patients (20.9%) on and 24 patients (20.7%) off anticoagulation therapy died. Conclusions Active cancer was a major cause of recurrent VTE during anticoagulation therapy as a patient-related factor, while sub-optimal intensity of anticoagulation therapy was a major cause of recurrent VTE during anticoagulation therapy as a treatment-related factor, particularly in patients without active cancer.